IRS Substitute Form
W-9
Request For Taxpayer Identification Number and
Certification
Return form to the
requesting IU department
(For Use By U.S. Citizens, U.S. Entities, Or Resident Aliens Only)
Under the United States Internal Revenue Code, Indiana University is required to obtain Taxpayer Identification Numbers
(TIN) when making reportable payments to individuals or entities. Certain payments may be subject to a backup withholding
rate of twenty-eight percent when this information is not provided. The IRS may also assess a penalty of $50 per form unless
failure to comply is due to reasonable cause and not willful neglect.
Legal name (as shown on your income tax return and matches TIN number listed in Part I)
Print or Type
See specific instructions on Form W-9 Instructions
REQUIRED
Allowable
TIN types
(SSN or EIN)
noted next to
each tax
classification
type
Business name (only use when “doing business as” (dba) is a different name than the legal name listed above)
REQUIRED - Must choose only one
Check appropriate box for federal tax classification
Individual (SSN)
Single Member LLC (SSN/EIN) Name = Individual
Estate/Trust (EIN)
Sole Proprietor (SSN/EIN)
LLC (EIN) Enter Tax Classification Code ______
Non-Profit Organization (EIN)
C Corporation (EIN)
(C = C Corporation, S = S Corporation, P = Partnership)
Governmental (EIN)
S Corporation (EIN)
Partnership (EIN)
Other ____________________
Check the box below if you perform health care or legal services
Health Care Services
Exemptions (see Form W-9 Instructions)
Legal Services
Exempt Payee Code _______
Exemption from FATCA Reporting code (if any) ________
Address (number, street, and apt. or suite no.)
City
Part I
REQUIRED
State
Zip Code
Taxpayer Identification Number (as reported for tax purposes and matches legal name above)
Social Security Number/ITIN
(Legal name above must be individual name)
REQUIRED
___ ___ ___ - ___ ___ - ___ ___ ___ ___
*** OR (only one) ***
Employer Tax ID Number
Part II
___ ___ - ___ ___ ___ ___ ___ ___ ___
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued
to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all
interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.
Signature of U.S. person
Date
Sign
Here
9/2014
REQUIRED